Spotlight on Social and Behavior Change Communication (SBCC) Insights and Impact Based on Client Perspectives Lynn M. Van Lith Senior Technical Advisor-HIV/AIDS, JHU∙CCP The RESPOND Project End-of-Project Forum

September 18, 2014 Washington DC

1. Results-oriented

2. Science-based

3. Client-centered

4. Participatory

5. Benefit-oriented

6. Service-linked

7. Multi-channeled

8. High-quality

9. Advocacy-related

10. Expanding to scale

11. Programmatically sustainable

12. Cost-effective

12 Elements of Strategic Communication

SBCC Is a Systematic and Strategic Process

P Process

Step-by-step framework

Road map leading to strategic and participatory programs

Grounded in theory

JHUCCP

India: Spotlight on the Client

PEER Approach to NSV in Uttar Pradesh, India

1. Identify: – Knowledge, attitudes, and

perceptions of NSV – How best to support positive

attitudes and acceptability – How those with vasectomy are

perceived by community members

2. Understand quality of care issues

3. Assess nature of spousal communication around FP

4. Identify best ways to frame benefits and tailor messages to promote NSV

Wife is initiator, but husbands often reject FP

Common belief that FP is concern of women; men are actively uninterested

Resistance to NSV is ↑ among men and women

5 Main Barriers 1. Extreme fear of weakness (biggest factor) 2. Impact on sexual performance 3. Fear of procedure 4. Fear of failure: severe consequences for

woman, charges of infidelity and eviction 5. Availability of other methods

Emergent Themes

Translating Research to Strategy

1. Focus primarily on couples who have completed their family size 2. Promote NSV at or soon after birth of 2nd and/or 3rd child (PPFP) 3. ASHAs are key link 4. Address barriers in messages

– Powerful testimonials with simple assurances from qualified doctors 5. Share positive testimonials:

– Emphasize permanence of NSV with man’s continued ability to work and provide for family

– Build on perception that only strong/courageous men undergo NSV—reposition as “manly”

– Promote simple, painless, and stitch-free nature—avoid use of “operation” 6. Focus on men directly

Demand-Side Approaches

Supported NRHM, Governments of Uttar Pradesh and Jharkhand in improving messaging

Held skills-building on interpersonal counseling in sessions with ASHAs and satisfied acceptors

Conducted ongoing coaching of ASHAs and satisfied acceptors

Developed NSV movie

Distributed posters and brochures on NSV

Aired radio spots to increase awareness and acceptance of NSV

Key Messages

NSV does not cause physical weakness: – Explain it is not surgery; no major blood loss involved – No incision, hence no suture; confirm with doctor before accepting NSV

NSV is a simple procedure, completed in 10–20 minutes: – Client can go home on his own in an hour after NSV

NSV does not cause sexual weakness – NSV does not affect

sexual performance – Man can talk with satisfied

acceptor

Impact

Uttar Pradesh (UP): 44 facilities supported in nine intervention districts Jharkhand: 19 facilities supported in three districts Three-fold increase in NSV acceptance (2% to 11%) in nine UP project districts Jharkhand: significant increases in West Singhbhoom, Bokaro, and Ranchi No cases of complications reported in 2012 from any project districts

Kenya: Spotlight on the Community

COMMPAC Goal and Objectives

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1. Increase community knowledge of the danger signs of abortion-related complications, locations of services, and family planning (FP)–related information and services

2. Build capacity to address PAC and FP needs

3. Encourage involvement of most marginalized in community action

4. Mobilize communities to prevent and treat incomplete abortion

5. Strengthen service delivery points providing PAC and FP

Goal: Increase communities’awareness and use of postabortion care (PAC) and related services to reduce maternal

mortality and morbidity

Intervention Design

18-month intervention MOH Community Strategy w/DHMTs – CHEWs and CHWs as primary links—

sustainable structures

Facilitate Community Action Cycle for PAC – Train CHEWs/CHWs – Support them to conduct community

mobilization – Support groups to develop and implement

action plans – Mentor to build capacity of CHEWs/CHWs

Train providers in comprehensive PAC services Build provider-community partnerships

Increased knowledge of danger signs or complications

Increased tendency to seek care for PAC/bleeding

Providers experienced increased confidence about offering PAC services

Improved perceptions of the quality of care available for PAC

Increased proportion of women who sought PAC services reporting having received FP information and methods at intervention sites

Evaluation showed evidence of community empowerment to take action for their own health

Impact

Burkina Faso and Togo: Spotlight on Couples

Formative Research

Perceptions of one’s husband’s approval of FP affect use

As women age, have more children, spousal discussions about FP increase

Decision making involves complex process of negotiation

Few tools model couple communication on FP—even less so in West Africa

Builds on Africa Transformation™

Goal: to better understand couple communication in FP uptake

Findings Informed SBCC Activities

FP pamphlet

Posters Flipchart and discussion guide Radio shows – Featured real providers, modern FP users,

community health agents, and religious leaders Radio spots on community radio stations – Targeted service providers, Christian religious

leaders, Muslim religious leaders, and men 4 videos on couple communication – Implant, IUD, vasectomy, female sterilization

Used in hospital/health center waiting rooms as tools for providers to discuss FP in counseling sessions and group talks

Poster

LA/PM Couple Communication Video Profiles

Impact

Clients and providers described materials as helpful and effective: – 38% of providers had no counseling job aid before – Others noted it was more comprehensive than other guides

Clients and providers expressed deep appreciation of radio activities:

“Those messages changed the mind of my husband to accept this method.” —An implant client in Togo

“Many learn information from the shows and come for more information on family planning from us. Thus, these shows are very important.”

— A nurse in Burkina Faso

“For us women, they are messages of liberation from the miserable conditions we live in after closely spaced births.”

— An implant client in Togo

Videos and Accompanying Discussion Guides

http://www.respond-project.org/pages/pubs/videos.php

Spotlight on Multicountry Analysis for Advocacy

Increasing use of contraception among women with a desire to limit future births will: – Reduce high-risk, high-parity births – Contribute to the reduction of maternal mortality

Birth-limiting behavior has a greater impact on fertility rates than birth spacing

Limiting a major factor driving fertility transition in Africa, though less is known about women with a desire to limit

Proportion of women in Sub-Saharan Africa who want to limit rather than postpone childbearing is rising steadily

Increased demand for FP comes mainly from rising proportion of women who wish to cease rather than postpone childbearing

Rationale for Paying Attention to Women with Desire to Limit Future Births

Data and Methods

Sub-Saharan African countries with DHS after 2000 eligible for inclusion

Selection based on having sufficient number of users (25+) of each method categories 1. Short-acting methods 2. LARCs 3. PMs 4. Traditional methods

Also included were high-population countries (Ethiopia, DR Congo), to ensure that analyses were representative of the region’s population

Used STATA Version 9; SPSS Version 20; StatCompiler

Demand for Limiting Is Strong

Although fertility desires are generally high, demand for limiting births (met and unmet need) is strong

37% of all demand for FP is for limiting

9% of women reported they had wanted no more children at the time of their last birth

Demand to limit exceeds demand to space in one-third of the countries

More women hope to use LARCs or PMs in the future

Demand for Spacing and Limiting Births, by Age (averages weighted by population of women of reproductive age for all 18 countries)

Conclusions

Fertility decline is likely to continue in Sub-Saharan Africa

If this trend holds, more and more women will want to limit, requiring advance preparation by FP programs

Many Sub-Saharan African women want to limit, and are already taking action to do so

Younger women have a significant unmet need for limiting

Programs must pay attention to growing number of women with an intention to limit—this is a unique audience, long overlooked and underserved

www.respond-project.org

Photo credits: Slide 1, C. Svingen/EngenderHealth; Slide 4, Staff/EngenderHealth; Slide 6, Staff/EngenderHealth; Slide 11, Staff/EngenderHealth; Slide 16, A. Jackson/ EngenderHealth; Slide 23, Staff/EngenderHealth; Slide 28, B. Jones/EngenderHealth; Slide 30, E. Uphoff/EngenderHealth.